Do Not Attempt Resuscitation (DNAR) – The Role of the School Nurse
It is the position of the National Association of School Nurses (NASN) that each student with a Do Not Attempt Resuscitation (DNAR) order benefits from having an Individualized Healthcare Plan (IHP) and an Emergency Care Plan (ECP) developed by the registered professional school nurse (hereinafter referred to as school nurse). While it is not a common occurrence for children with a Do Not Attempt Resuscitation (DNAR) order to die while at school, it is important to develop a plan in the event it does happen (DeMitchell & Thompson, 2017). Furthermore, a DNAR order for a student needs to be reviewed individually at the district level with input from the school district’s legal counsel for consideration of state and local laws and according to district DNAR policy. As advocates for their students, school nurses work with the school team, the parents, and students’ healthcare provider to meet the students’ underlying healthcare needs as well as establish protocols and practices that enable students to receive best practice care throughout the entire course of their condition while they are in school.
In 1974 the American Heart Association declared that cardiopulmonary resuscitation (CPR) was not indicated for all patients. Individuals with terminal, irreversible illnesses where death is the expected outcome would not benefit from CPR (Larcher, Craig, Bhogal, Wilkinson, & Brierly, 2015). In 1994 the American Academy of Pediatrics (AAP) and the National Education Association (NEA) issued guidelines on foregoing life-sustaining CPR for children and adolescents (AAP, 2010). Originally, the physician order was referred to as a Do Not Resuscitate order (DNR), which evolved to Do Not Attempt Resuscitation (DNAR), and sometimes Allow Natural Death (AND) (Selekman, Bochenek, & Lukens, 2013).
The number of children and young people with palliative care needs is rising (Peate, 2015). According to Singh, Click, McCracken, and Hebbar (2017), pediatric hospice and palliative medicine physicians strive to “relieve suffering, improve quality of life, facilitate informed decision-making, and assist in care coordination” with the greater goal of improving the quality of medical care delivered to patients and their families during acute and chronic illness. Students with chronic or terminal conditions, when possible, belong in school. Students benefit from participation in all school activities, including the psychosocial and emotional benefits of interacting with peers and maintaining their daily routine (Klick & Hauer, 2010; Zacharski et al., 2013). State and local laws/regulations vary regarding DNAR orders for student.
Currently, the order to provide comfort care is part of a much broader palliative care plan that may include Medical Orders for Life Sustaining Treatment (MOLST) (APA, 2010). In some states, school nurses are required to honor DNAR orders. In the case of ABC and DEF School v. Mr. and Mrs. M in the state of Massachusetts (1997), the court ordered the school to honor the DNAR order for a medically fragile child (Adelman, 2010; Deutch, Martin, & Mueller, 2015; Putman, 2017). In addition, the court refused to allow the school to shield staff from liability should they choose not to honor the DNAR order (Adelman, 2010).
According to the 2011/2012 National Survey of Children with Special Health Care Needs (CSHCN), approximately 14.6 million children ages 0-17 years in the United States, or 19.8 %, have special healthcare needs. The percentages of CSHCN range from 14.4%-26.4% across 50 states and the District of Columbia (Centers for Disease Control and Prevention’s National Center for Health Statistics, n.d.). The AAP (2010) estimates that, on any given day, there are 3900 school-age children who are within six months of dying from chronic health conditions (as cited in Putnam, 2017). According to a Centers for Disease Control and Prevention [CDC] survey, the percentage of schools where health services staff reported the need to follow a DNAR order increased from 29.7% in 2000 to 46.2% in 2006 (Brener, Wheeler, Wolf, Vernon-Smiley, & Caldart-Olson, 2007).
Growing populations of students with chronic health conditions—including terminal and irreversible illnesses, congenital defects, injuries, and malignancies, where death may be the expected outcome—are now routinely attending school (Klick & Hauer, 2010; Adelman, 2010). The Office for Civil Rights of the DOE (2016) states that a free and appropriate public education must be provided to each person with a disability (a person with a significant mental or physical impairment, or history of such, that substantially limits a major life activity). Services must be provided in the least restrictive environment.
The National Association of School Nurses’ Framework for 21st Century School Nursing Practice™ directly aligns with care coordination as a key concept in the school setting (NASN, 2016). Decisions to limit treatments – or which treatments should be given – are made by clinical teams in partnership with the parents and child, if appropriate (Larcher et al., 2015). Communication within healthcare teams and with parents and children is important and needs to include those in the community who also have a duty of care to the child. All clinical staff need to have access to continuing professional training and education in communication skills, ethics and the issues raised by decisions to limit treatments (Larcher et al., 2015).
Families face many challenging issues but perhaps none more sensitive and emotionally challenging than that of an order for DNAR. A DNAR order is not abandonment of medical treatment and does not replace any obligation to provide quality care; rather it is part of the management plan. A DNAR order is in place to facilitate the individual with a terminal illness receiving the best care possible at the end of life. The healthcare provider(s) and the family review and determine this plan to communicate the difficult decision to refrain from life-sustaining treatment that would be ineffective or to guide when risks of treatment outweigh the benefits. A DNAR physician order for the school is implemented in the context of palliative care, including comfort measures as well as addressing the emotional and spiritual needs of the student (AAP, 2010).
The school nurse is a specialized practitioner who focuses on education and health and provides an important link between the school, home, and community (Perry 2014). Care plans for students with DNAR orders should be implemented in the context of palliative care and include comfort measures (Zacharski et al., 2013). School nurses must be knowledgeable about state and district regulations, community support systems, resources for advocacy, and the process of writing and implementing IHPs for students with DNAR orders (Zacharski et al. ,2013). In addition, an ECP may be required to give non-medical staff information necessary to provide appropriate medical care for students who have DNAR orders (Larcher et al., 2015). Each palliative care request must be reviewed with the student's healthcare provider, determining orders and direction for his or her client, and with the school nurse, leading the school team in order to provide the best care possible in the school setting for the student (AAP, 2010). The school nurse and staff focus on what can be provided for comfort rather than on what is not being provided (Zacharski et al., 2013).
School nurses play a pivotal role in supporting students with DNAR orders through the development of an IHP and ECP (AAP, 2010; Peate, 2015). The school nurse is the school health professional with the knowledge, experience, and skills to coordinate the care for a student with a DNAR order, linking the school with the medical and community services needed by the student, while advocating for the student and family to ensure access to a free and appropriate education (DeMitchell & Thompson, 2017; Selekman et al., 2013). School nurses along with the school district should create clear, written policies related to DNAR with regard to their state laws and statutes (Perry, 2014).
ABC and DEF School v. Mr. and Mrs. M, 26 IDELR (LRP) 1103 (Super. Ct. Mass., 1997) .
Adelman, J. (2010). The school‐based do‐not‐resuscitate order. DePaul Journal of Health Care Law, Winter, 197‐214. Retrieved from http://via.library.depaul.edu/jhcl/vol13/iss2/3
American Academy of Pediatrics. (2010). Policy statement: Honoring do‐not‐attempt resuscitation requests in schools. Pediatrics, 125(5), 1073‐1077. doi: 10.1542/peds.2010‐0452
Brener, N.D., Wheeler, L., Wolf, L.C., Vernon-Smiley, M., Caldart-Olson, L. (2007). Health services: Results from the School Health Policies and Programs Study 2006. Journal of School Health,77(8),464–485. doi: 10.1111/j.1746-1561.2007.00230.x
Centers for Disease Control and Prevention’s National Center for Health Statistics. (n.d.). National survey of children with special health care needs. NS-CSHCN 2009/10. Data query from the child and adolescent health measurement initiative, data resource center for child and adolescent health website. Retrieved from http://childhealthdata.org/browse/survey/results?q=1792&r=1&g=376
DeMitchell, T. A., Thompson, W. C., (2017). Do not attempt resuscitation orders in our schools: The unthinkable ethical dilemma for educators. Rutgers Journal of Law & Public Policy, 14(3), 287-313. Retrieved from http://www.rutgerspolicyjournal.org/sites/jlpp/files/Vol.%2014%20Is.%203.pdf
Deutch, J.M., Martin, L. G., & Mueller, J. A. (2015). Managing students with health issues: Section 504 plans, DNR orders and contagious disease. National School Boards Association. Retrieved from https://cdn-files.nsba.org/s3fs- public/file/16_FINAL_Deutch_Martin_Managing_Students_with_Health_Issues_Paper.pdf?hXFC9ZaGKn_7f5xaVnOdp6gdTCPI1KCZ
Klick, J. C., & Hauer, J. (2010). Pediatric palliative care. Current Problems in Pediatrics and Adolescent Health Care, 40(6), 120‐151. doi:10.1016/j.cppeds.2010.05.001
Larcher, V., Craig, F., Bhogal, K., Wilkinson, D., & Brierly, J. (2015). Making decisions to limit treatment in life-limiting and life-threatening conditions in children: A framework for practice. Archives of Disease in Children, 100(suppl 2). doi: 10.1136/archdischild-2014-306666
National Association of School Nurses. (2016). Framework for 21st century school nursing practice. NASN School Nurse, 31(1), 45-53. doi: 10.1177/1942602X15618644
Peate, I, (2015). Contributing towards improved end of life care for children. British Journal of School Nursing, 10(4). https://doi.org/10.12968/bjsn.2015.10.4.191
Perry, A. (2014). The ethics of pediatric resuscitation in public schools. Advances in Medical Ethics, 1(2), 1-6. doi:10.12715/ame.2014.1.2
Putman, S. (2017). Do not attempt to resuscitate (DNAR) in the school setting. In C.A. Resha & V. L. Taliaferro (Eds.). Legal resource for school health services (pp. 243-252). Nashville, TN: SchoolNurse.com.
Selekman, J., Bochenek, J., & Lukens, M. (2013). Children with chronic conditions. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed., pp. 700‐783). Philadelphia, PA: F.A. Davis Company.
Singh, A. L., Klick, J. C., McCracken, C. E., & Hebbar, K. B. (2017). Evaluating hospice and palliative medicine education in pediatric training programs. American Journal of Hospice & Palliative Medicine, 34(7). doi: 10.1177/1049909116643747.
US Department of Education, Civil Rights Division. (2016). Parent and educator resource guide to Section 504 in public elementary and secondary schools. Retrieved from https://www2.ed.gov/about/offices/list/ocr/docs/504-resource-guide-201612.pdf
Zacharski, S., Minchella, L., Gomez, S., Grogan, S., Porter, S., & Robarge, D. (2013). Do not attempt resuscitation (DNAR) orders in school settings: Special needs school nurses review current research and issues. NASN School Nurse, 28(2) , 71‐75. doi:10.1177/1942602X12472540
Acknowledgment of Authors:
Cindy Begley, BSN, RN, NCSN
Teresa Cowan, BSN, RN, CSN
Doreen Crowe, MEd, BSN, RN
Pam Allsbrook, MSN, BSN, RN, NCSN
Karen Graf, MSN, RN-BC, APHN-BC
Acknowledgement of 2012 Issue Brief Authors:
Christine M. Tuck, MS, BSN, RN, NCSN
Alicia Jordan, BSN, RN, NCSN
Patrice Lambert, MSN, RN, SNC
Jessica Porter, BSN, RN, NCSN
Revised: June 2018
Suggested citation: National Association of School Nurses. (2018). Do not attempt resuscitation—The role of the school nurse (Position Statement). Silver Spring, MD: Author.
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.